Standardizing Dictated Documents

Dictated medical notes and other types of transcribed patient records are usually available in electronic form, but have traditionally not been very useful in the context of an electronic medical record (EMR) system. Transcribed records follow a variety of formats depending on the clinical setting and type of transcription service used, making them difficult to search.

“There's no real structure to the narrative that's being inserted into the EMR,” says Jay Cannon, president of the Medical Transcription Industry Association (MTIA), Chicago. “The information is visibly accessible, but within the system it's just a text blob.”

Adds Harry Rhodes, director of practice leadership at the American Health Information Management Association (AHIMA), Chicago, “Presently, a transcribed report looks like a black hole to the average EMR system. It can see there is a document there, but it can't see inside the document.”

Now, a new standard, based on the Health Level Seven (HL7) Clinical Document Architecture (CDA), could help improve the utilization of these types of documents.

Called “CDA for Common Document Types,” this new standards project was led by MTIA, AHIMA, the Modesto, Calif.-based Association for Healthcare Documentation Integrity (AHDI), and speech recognition and transcription service provider M&ast;Modal, Pittsburgh. The project is looking to create implementation guidelines for dictated clinical documents, then present them to HL7 for review.

The Guide for History & Physical Reports was submitted for balloting at the end of March. Other guidelines will include consult notes, discharge summaries, operative notes and other types of dictated documents, and will be submitted based on HL7's balloting schedule.

Using formatted, structured text across applications and facilities could potentially increase the amount of information available to EMR systems, and to regional health information exchanges (RHIOs). Standardized documents would also enable data mining across multiple patient records.

“To create an index of subject headings, or to be able to pull comparable information from a number of reports into a repository to look at them together depends on having some structure to the reports,” says Wes Rishel, research vice president at Gartner Inc.

“This will enlarge and enrich the flow of data in the EMR, and that will help speed the development of interoperable clinical document repositories,” says Rhodes.

Several software and service companies have already pledged support. In addition to M&ast;Modal, six other vendors served as project benefactors, including Spheris, MedQuist, InterFix, Precyse Solutions, Webmedx and MDinTouch. Several large hospitals and health systems also participated.

In addition to software and service providers integrating the standard into their products, clinicians and transcriptionists would also need to follow the new format. According to Rishel, in most cases doctors would just need to follow a new template for their reports.

“Increasingly, there is pressure on physicians to use a method of dictating that makes it easy for their colleagues to get the necessary information out of the report,” Rishel says.

Adds Cannon, “As far as the doctors are concerned, there will be some small associated changes in the dictation pattern, but, for the most part, the information will remain the same. The content won't change. This might just change the order of the content. But being conscious of that order will improve the quality and completeness of the narrative.”

The workgroup has evaluated thousands of documents in the process of developing the guides. The history and physical report guideline, for example, is based on more than 15,000 samples from 30 different providers and healthcare sites.

If widely adopted, the standard could make documents easier to share between providers, and even help improve HIPAA reporting by making it easier to locate specific data in a patient record.

“For physicians and other clinicians, CDA-based documents are technically much easier to pass from one setting of care to another in electronic format,” says Daniel Russler, M.D., vice president of clinical informatics at Oracle, Redwood Shores, Calif. “Doctors will have better access to information with less work, and at less cost.”

Brian Albright is a contributing writer based in Columbus, Ohio.

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